Medicine’s Code of Silence About Mistakes

Have you ever heard the phrase “see no evil, hear no evil, speak no evil”? Wonder where it comes from? This proverb about three monkeys is often used to refer to people who deal with bad behavior by pretending it hasn’t happened. In other words, when a mistake happens or someone screws up, the solution is to look the other way rather than to acknowledge the problem and try to fix it.
This happens far too often in health care. Medicine has developed a code of silence when it comes to mistakes that harm patients. Although almost every hospital has clear guidelines on reporting errors, a new report from the Office of the Inspector General of Health and Human Services suggests that problems are often ignored or swept under the rug.
The study focused on Medicare patients and estimated that more than 130,000 experience accidental harm in the hospital each month. An in-depth analysis of 293 instances in which patients suffered revealed that only one in seven problems (40) were reported to hospital administrators. Even fewer of these cases (28) were thoroughly investigated and a tiny fraction (5) led the hospital to change its standard practice or policy to ensure that the error would not be repeated.
The Inspector General, Daniel Levinson, pointed out that hospitals are required to track such events as a condition of being reimbursed by Medicare. The study found, however, that many hospital employees do not recognize situations that result in patient harm, or they may assume that the problem is so common it does not need to be reported. In other cases, employees may worry about being blamed for the error and fear repercussions.
The trouble is that the system can’t fix a problem it doesn’t detect or acknowledge. The Inspector General’s report is not the first one to show that serious events are underreported, only the latest. A study published last year in the policy journal Health Affairs (April, 2011) showed that only 4 major injuries out of 354 events detected through a careful analysis of records had been reported to hospital management. That’s just a bit more than 1 percent. And if you think these stats apply only to older people, think again. Health care harm is just as likely to go unreported for everyone else as well.
No other professional could ignore so many mistakes or mishaps. Pilots must report close calls. Airplane accidents are investigated thoroughly by the National Transportation Safety Board. No such entity exists to track health care harm in hospitals, nursing homes, outpatient surgical centers or doctors’ offices.
When patients suffer a medical mishap they want an acknowledgment that something bad happened. They appreciate an apology from the health care provider and hope for a promise that changes will be made to protect others from experiencing the same complication. They also may want the institution to pay their medical bills for the damages that occurred. There is no greater insult than to be charged thousands of dollars for care resulting from a series of mistakes. Yet that happens every day in this country.
We have all heard how important it is for patients to take personal responsibility for their lifestyle choices. We think it is also critical for providers and institutions to be accountable for their mistakes.
Our new book, Top Screwups Doctors Make and How to Avoid Them, reveals the healthcare cover-up in much greater detail. You will learn how to protect yourself or a loved one from misdiagnosis, medication mistakes and drug interactions. You will learn about the most common screwups that are made for conditions like:• Alzheimer’s disease
• Arthritis
• Asthma
• Attention Deficit Disorder
• Back Pain
• Breast Cancer
• Celiac Disease
• Deep Vein Thrombosis (DVT)
• Depression
• Diabetes
• Fibromyalgia
• Heartburn
• Hypothyroidism
• Migraines
• Osteoporosis
• Prostate Problems
• Tick Borne Diseases
Should you wish to share your story below in the comment section, we would like to learn about your experience with the healthcare system, positive or negative. Here are just a few medical screwups that we have recently heard about after our radio show on the Inspector General’s report:
+++++++++++++++++++++STORIES FROM LISTENERS:
In Sept. 2007, was hospitalized for a mitral valve repair. I was in excellent health except for the mitral valve prolapse, and my doctors told me, “You’ll be in and out in 5 days.”
I flat-lined three times during the operation and was on life support for a week. I spent a month in the hospital ICCU for a month. When I returned home I saw a physical therapist, occupational therapist and nurse for a month.
I had been given a 20% chance to live the first week. The surgeon told my husband, “Shit happens.”
My chart was stamped: “angry spouse.” He was supposed to be happy? But he told the surgeon that if I were brought back to health, there would be no lawsuit because we are not litigious people.
When I went back for my final checkup and release letter for work, I asked the surgeon, since he had had a couple months to investigate, why was it that I had all these problems?
He said…exact words…”I’ll tell ya what, you’re going to die before me, so when you get to heaven, you ask God what happened, and when I get up there, you can tell me.” Yes, he was a cocky, relatively young surgeon, who would have had a broken nose if I had had my strength back. And if I didn’t want to sue before, I did after that comment.
No one ever spoke of any problems, and to date, the hospital refuses to send me my entire record.
V. P., Jan 7, 2012
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I was listening to your radio program this morning and I heard you talking about wanting to hear of narrowly missed disasters in health care. On Dec. 6th, I had what felt like a very large and painful gas bubble in my abdomen that also seemed to be causing reflux. I was in severe pain but drove myself to the ER closest to home.
When I arrived they gave me nothing for pain relief for nearly three hours because, I was told by an ER physician, “If you need surgery the doctor will want to examine you before you are medicated.” Not knowing any better, I reluctantly went along with the plan.
Meanwhile, they did x-ray, blood work, and urine sample, but found nothing. So the ER physician chalked it up to a bad case of constipation and gave me something for the pain. Minutes after taking it, I began dry heaves. When the ER physician returned, he was suprised I was throwing up, but without any further investigation decided I was having a nausea reaction to the pain medication and sent me home. After I quit the dry heaves I began to feel better and didn’t think any more of it.
Four days later, my wife and I went to join friends for an early Christmas get-together. We stopped along the way to gas up the vehicle and pick up a pastry and drink for each of us. Mine was on the rich side and 20 minutes later the severe pain in my abdomen returned. This time it snowballed to such pressure that I had all I could do to breathe. My wife exited the freeway to the closest hospital and right away they gave me something for the pain. In addition to the other tests they re-ran like the previous hospital had, they also called for an ultra-sound. That’s how they discovered a huge stone in my gallbladder.
When they did surgery that evening, they began the laparoscopic procedure only to find my gallbladder had swollen to four times its normal size, with one wall so decrepit that it was clear it could burst at any time and cause peritonitis. What would have normally been a 45-minute procedure took nearly three hours as they debated several times whether or not to open me up full-bore. Eventually they widened the incision at my belly button by three times the usual and slipped a bag around my gallbladder in case it burst while removing it.
After they finally got it out, the doctor inspected it and found that not only did it have the one large stone, but also “thousands of little ones.” He said I won the prize for the most difficult gallbladder surgery he had ever performed.
Now I am only a layman, but it seems to me that if they had run an ultra-sound test at the first ER visit this could have avoided a bunch of trouble. We complained to the first hospital, but 27 days later we still haven’t heard anything definitive regarding an investigation. It seems like they are dragging their feet on this. Talk about frustrating!
It sure was scary that Saturday morning when I couldn’t catch my breath and didn’t know what was going on. My health and my life were at risk from the danger of peritonitis due to the possibility of my gallbladder rupturing — all for a lack of curiosity and concern.
Steve from Wisconsin, Jan. 7, 2012
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We welcome comments below from others who may have experienced health care harm. We also want to remind you that we wrote our latest book to try to protect you and those you care about from just these kinds of terrible events:Top Screwups Doctors Make and How to Avoid Them

16 Thoughts Shared

lrs

June 13, 2014 at 11:05 am

If I’m not mistaken GM is in trouble with the government because they took to long to report a faulty switch and that 13 people died, however in medicine 100,000 people die each year and every one looks the other way strange.

naomi b.

May 23, 2014 at 1:50 pm

We used a licensed Ophthalmologist for several years. Very busy and we assumed competent. One day, with little preamble, he suggested my husband make a date to have cataracts removed; he had never mentioned that my husband HAD a cataract before!
We decided to go see another Ophth. At the first visit the new MD said that the pressure in the right eye was very high and that we should see a super-specialist. Long story short: My husband had serious glaucoma the previous doc. had never mentioned. Clearly it had been developing for a long time, and was never treated. Two kinds of drops have stabilized the glaucoma (NOT the same as curing it, which is impossible), but my husband’s right eye cannot see the top eye chart letters. He is legally blind, cannot see enough to walk unaided, cannot read, sees very little of the details on TV (for instance, which actor is which?). In short, he is almost completely blind. (One possible treatments, injections into the eye, were rejected because a possible side-effect is a stroke; he’s already had one and did not want to risk another.
I would sue the first MD for, at least, some money – BUT TRY TO FIND A DOCTOR WHO WILL TESTIFY THAT POOR TREATMENT RESULTED IN BLINDNESS.

Mariellen G.

July 20, 2012 at 5:18 pm

So, I’m a mental patient. My very first day in the hospital (November 1978) the shrink gave me a pelvic. I don’t know what you think about my putting it this way, but I could tell by the vibes this was not medically correct procedure. This was not about finding out if I’d been raped.
Over the next half-dozen years, I met several other women who’d been given pelvics by this same fella. Finally, I broke silence: I asked my then-psychiatrist, who I knew had my best interests at heart, “Is it ever appropriate to give a woman who is a mental patient a pelvic?” The doctor slapped my file shut and said, “Sometimes.” End of discussion. Medical fraternity at work.
It was several more years before some woman sued him… and the other docs ran him out of town… but not out of the profession. Last I knew, the fella was still practicing psychiatry in a southern state.
How do I say? Nowadays I interview a doc before I let him treat a hangnail.

clw

April 4, 2012 at 11:22 pm

A few years ago I raised up under a tree branch and hit my head, seeing stars and becoming a little dizzy, but only for a moment. It barely broke the skin. During the following week I took a trip to a family reunion (driving myself) and suffered what I thought were very bad sinus headaches, especially driving the hour and a half to my home. Next day, working in the garden some stuff fell on my head from a tree and I shook it hard to dislodge them from my hair and I felt a searing pain and suddenly the horrible headache became unbearable.
Medics came and asked me if I’d ever had migraine headaches and I said I had, but 30 years ago. I insisted this wasn’t a migraine, I had felt something burst inside my head when I shook it and the pressure was the worst I’d ever felt. I vomited. Still he insisted it was a migraine because I once had one. I’ll never admit to that again. I didn’t connect the head bump the previous week, for the same reason, I guess, that we wonder where a bruise on our arm came from. Still, I knew I was in serious trouble.
I tried to explain again that it was not a migraine, but he didn’t listen. The fireman told the medic from the Medic 1 aide car, that I had a history of migraine. They finally called a private ambulance company, which took forever to arrive (as a non-emergency) and I was sent to the wrong hospital for neurological events, but by the time we were almost to the hospital I passed out. The first hospital did a CT scan and sent me to the right hospital and I finally ended up having a craniotomy for a severe subdural hematoma. I was minutes away from death by the time I went into surgery.
The blood filled my skull and pushed my brain down into my brain stem. It is a miracle I’m still alive. One third of my skull was in the refrigerator (or was it the freezer?) I was not thinking too well at that point. After the surgery, a nurse and aid were lifting me with the pull-sheet to scoot me higher in the bed, and threw me against the headboard, hitting my head which had only a soft bandage protecting my brain. For weeks afterward, I had nightmares where I was pleading with this medic to get me to the hospital because I was dying and he just sat in my chair and told me he liked my house.

TL

February 2, 2012 at 2:46 pm

My local pharmacy at the Giant grocery in Bethesda MD has not made a mistake before in ten years I have been there. However, just to show that these things happen, in Dec, 2011 they managed to give my 13 year old daughter the antibiotics prescription for someone else as his name is listed on the bottle.
The pharmacy manager called after 3 days and came personally to my home the next day to deliver the correct pills. Fortunately, no harm was done, and apparently an “inexperienced person filled similar prescriptions didnt double check as they should that everything is correct.”
Moral of this is not to take for granted all is correct, even minor items.

MG

January 21, 2012 at 7:33 am

I work in a VA hospital.
I would like to share a couple of comments on medical mistakes and transformational change in the VA.
First and foremost, I love the work I do with Veterans and have done this work for over 30 years. However, there has been a disturbing trend I have noticed in two areas:
1) I below to an eMail group that has a distribution across the country. Administrators are now fingering nurses for medication mistakes and presenting them with severe punitive action. (One experienced RN gave a fresh post-op patient a dose of IV Morphine exceeded the dose that was ordered by the surgeon. Even though she immediately recognized the mistake, immediately reported to the managers and surgeon; AND the patient stated this was the first time the patient pain relief was accomplished and there was no adverse event) –> within a week, the RN was presented with termination papers on the very first infraction. The RN became the poster child for perpetuating a conspiracy of silence.
2) I am involved with patient centered care and thoroughly embrace it. The disturbing issue is that some services proposed (health coaching, etc) is the outsourcing or contracting out these services by for profit companies… and NOT a VA EMPLOYEE. I realize that some of this is a costing issue, but many providers’ education was funded by the VA and they are unable to use their education.

FJR

January 17, 2012 at 11:17 pm

How a book on the mistakes that pharmacist make in the course of their work. I would suggest a title like “Screwups Pharmacists Make and How to Avoid Them”. I recently heard of a bright young pharmacist at a large big box chain drug store tell non English speaking Hmong man that the prescription was “done” and there were “no more refills”.
The man understood that he no longer needed his blood pressure medicines. A year later he went to the dentist with a tooth ache and discovered his blood pressure was 190/115. He then returned to his doctor only to find a significant drop in his renal function with a GFR of 30. The Hmong don’t believe in the concept of preventative care in the first place so when this bright intelligent young pharmacist said there were no more refills he felt he was cured.
We need more books with catchy marketable titles. “Screwups Pharmacologists Make On Behalf of Drug Companies and How to Avoid Them”. “How Pharmacologists are Used to Market Worthless Drugs To Generate Big Money for Their Drug Company CEOs” “How Pharmacists Sell Out To Big Chain Drug Store To Sell Pills As Fast As They Can and Make A Good Living”. These are important topics that need to be written about and the Graedons can cash in big.

DC

January 13, 2012 at 8:14 pm

When my mother was in an ICU in a Florida hospital we heard a crash out in the hall and saw that another patient (who was considered a risk for trying to get out of bed and walk) had fallen hard on the back of his head. Later we walked by as two nurses lied to his family, saying he had slipped but had been caught before he fell. We told the nursing supervisor what we saw.
More recently, my 86-year-old father went to three specialists (cardiologist, internal medicine and pulmonologist) in November complaining of shortness of breath and fatigue. All three told him he was fine. The cardiologist, who had been treating Dad for an irregular heart beat, told my sister he was concerned Dad was showing signs of dementia. The internal medicine specialist prescribed an anti-depressant.
He collapsed 10 days after seeing the pulmonologist, 20 days after seeing the cardiologist. The emergency room team said he had pneumonia and was almost at end stage congestive heart failure. He also had pneumonia. He died 10 days later.
I wrote the doctors two weeks ago asking what tests they performed to determine he was fine. Haven’t heard back and am guessing I won’t.

Dee

January 12, 2012 at 9:27 pm

On Dec 4, 2011, I boarded the Carnival cruise ship, Conquest, out of New Orleans for a week of fun and relaxation. After eating lunch and dinner aboard the ship on the first day, I became ill and went to bed early. Arose with a raging headache and projectile diarrhea. Reported to the Medical department, they gave me four Immodiums, which were ineffective. Returned the next day, and the day after that with the same symptoms, which were day and night.
I was placed in quarantine for 5.5 days of the 7 day cruise, with nothing offered but four Immodiums. Nothing helped. I saw two doctors and two nurses and they did have an ICU unit on the ship. Room Service was instructed to not deliver any food except juice, jello and broth to my stateroom three times a day. By the third day, I was so weak I couldn’t walk and each time I went to the Medical Dept. there were more and more people there. The day before we disembarked, one nurse gave me some tiny (unmarked) pills with instructions to take two every four hours (ten pills total).
The diarrhea stopped and I was able to get off the ship, but went directly home at which time the diarrhea had started again with a vengeance. I called 911 to take me to the ER. I was admitted and was there for five days, with (I counted them!) thirteen bags of potassium and two bags of antibiotic (Cipro and Flagyl) administered by IV.
The bottom line: “I think you just picked up a bad bug somewhere.” By the way, the doctor and nurse fees were prominently displayed at the entrance of the Medical Dept (MD=$90, RN=$50, per initial visit with follow ups only $10 less. I was not billed one penny for multiple visits to see medical personnel. Finally, on the last day of the cruise, I’m told by a traveling companion, she went to dinner and no one was allowed to serve themselves, but the servers with gloves presented food to the travelers. I Never heard from Carnival re a refund, reduced future or free fare nor not even an apology

CgD

January 12, 2012 at 6:57 pm

This happened many years ago and somehow I survived. I was having severe stomach pains which went around to the front and I was nauseous for days. I was about 20 years old and had been having “bouts” for the past couple of years on and off but with increased frequency.
The military doctor I went to did not order any tests because he decided that I was just lonely for my new husband who was stationed in Japan. How did he come to that conclusion? He had a daughter who was lonely for her new husband as well.
Within a few months I went overseas and got pregnant. I had a daughter and fortunately had no attacks during my pregnancy. But within 3 months of giving birth I had such an attack that I literally had to crawl on my hands and knees to get help from a neighbor.
It turns out that I had gall stones almost the size of golf balls and was extremely lucky that I had not had an attack during my pregnancy because both my baby and I could have died. We won’t even go into the nurse who wanted to give me an enema with Tide detergent rather than order and wait for something more “suitable”.

J.L.B.

January 10, 2012 at 5:01 pm

Several years ago my wife had a bad case of bronchitis. Our family doctor put her on an antibiotic. She felt better for a few weeks and then she started coughing severely again. We went back to the family doctor who is a great person and competent doctor. He was going to put her on another kind of antibiotic. I am an accountant and as an analytical person I asked him a sensible question which was “Why is my wife coughing so much after going through a round of antibiotic. Shouldn’t some more tests or x-rays be taken?”
He thought over my statement for a minute and then ordered a chest x-ray. What the x-ray revealed was that my wife had a mild case of pneumonia. There was some fluid in the bottom of her lungs which showed up on the x-ray. The doctor then ordered her to stay in bed for several days and prescribed another antibiotic. Bed rest is mandatory for pneumonia whereas a person can be up and on their feet if they have bronchitis.
If he had not discovered that she had pneumonia, she would have been on her feet and getting worse and worse. After that event whenever we went to the doctor he would ask me if I had any questions. He had a new respect for my observations/comments. He had almost made a wrong diagnosis which could have resulted in very serious situation for my wife.

Lovaduck

January 10, 2012 at 3:08 pm

As an aspiring pilot, I can tell you that the way safety has improved all the time on air travel, is because the ASRS (Aviation Safety Reporting System) allows for confidential reporting of incidents, and grants immunity to reporters. In our litigious society, this feature applied to medical mistakes would probably ignite irate responses from people who has seen loved ones suffer (as I did). When considering the need for KNOWING what’s up to be able to fix it, it makes a lot of sense to use similar techniques for the common good.
Remember, self-preservation is the strongest instinct…. if you want to remove denial and lies from medicine, you have to account for the simple fact that people’s altruism has a limit, and at some point in time they will choose their families, careers, and means of living over telling the truth. Accepting this simple fact should help. Other ways of addressing people’s grievances against doctors can be created that help give them some degree of restitution or repair for mistakes made…
Let me point out that a lot has improved in the medical field when adopting very simple rules used in aviation, like the use of checklists prior to surgery! Simple ideas that work…
Here’s an excerpt from Wikipedia that explains how this works:
“A notable feature of the ASRS is its confidentiality and immunity policy. Reporters may, but are not required, submit their name and contact information. If the ASRS staff has questions regarding a report, it can perform a callback and request further information or clarification from the reporter. Once the staff is satisfied with the information received, the report is stripped of identifying information and assigned a report number.”
Hope this helps.

Gin

January 10, 2012 at 11:44 am

Barri

January 10, 2012 at 11:26 am

Ten years ago I had lumpectomy for DCIS. I came out of the anesthesia alone in a recovery room. I felt like I was coming back from the dead and I really didn’t want to. The next day I had a severe headache and dizziness. Thirty days later I had to go back for a second surgery to “widen the margins.” While lying on the gurney talking with a different anesthesiologist I described my previous experience and suggested I was perhaps a little sensitive to the drug.
He looked shocked and told me “we always have you come out of the anesthetic in the O.R.” Turned out he was the Department head. And true to his word I returned to consciousness in the operating room and had no ill after effects. I never got a bill (and neither did my insurance company) for the first anesthesia.

PD

January 10, 2012 at 11:01 am

It was brought to my attention today by a well-informed source that Medicare is refusing to pay hospitals for patient care that is required as a result of hospital-induced illness or injury.
This, she says, has caused hospitals to not report such situations and within hospitals, has provoked departments to MOVE victims of hospital induced infections, injuries, etc., to other units so as to deflect criticism from their own practice. All this is a consequence of a faulty, performance-based reward system.

Paul43

January 10, 2012 at 6:06 am

I can’t wait to hear the rest f the incidents. I was an AIRCRAFT MECHANIC for over 20 years and I’ll never forget the first day I went to work. There were 12 of us starting on the same day and a Foreman sat down in conference room and went over the paperwork and the usual rhetoric and just as we were finishing up he said: “I want to tell you guys something that is extremly important—if you make a mistake I want you to tell whoever is charge of you–and most likely you will get instruction on how not to do if again—-BUT if you try and cover it up and we find out you are FIRED—EVERYONE MAKES A MISTAKE–EXCEPT THE PEOPLE WHO ARE NOT DOING ANYTHING!”
I think ever since there have been doctors they have had a GREATER THAN GOD attitude. When I go to see my DOCS I usually have a list of things I want to ask him about and extremly lucky to have 2 doctors who will spend all the time with me that is needed. More people need to QUESTION their doctors –especially when they are being prescribed new meds.

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